Annual chronic kidney disease review

Annual Chronic Kidney Disease Review

Section

Patient Status

Systolic “Higher”:

Diastolic “Lower”:

Heart Rate:

Height:

Weight:

Alcohol Consumption:

Units per week

Do you smoke?

Yes

How many do you smoke in a day?

Would you like to be referred to a smoking cessation adviser?

Yes

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you. For more information visit the Smokefree website.

Are you an ex smoker?

Yes

What date did you give up smoking?

Please use date format DD/MM/YYYY.

How many did you smoke in a day?

Activity levels:

Does not regularly exercise

Enjoys moderate exercise

Exercises regularly

When are you available to take a call in the next few weeks?

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Section

Patient Status